Forced Medications in the Restoration of Competency

Eric J. Chan; John Chamberlain

The Government Failed to Meet Its Burden of Proof That Forced Medication Was Substantially Likely to Restore Defendant's Competency

In United States v. Watson, 793 F.3d 416 (4th Cir. 2015), the Fourth Circuit Court of Appeals reversed the United States District Court for the Eastern District of Virginia's decision to grant the government's request that John Watson, Jr., be medicated by force, stating that the government had not met its burden of proving that the proposed treatment was substantially likely to restore his competency as required by Sell v. United States, 539 U.S. 166 (2003). Furthermore, the district court failed to give enough consideration to a defense expert's opinion that Mr. Watson, who had a diagnosis of delusional disorder, persecutory type, would be unlikely to respond to such treatment.

Facts of the Case

On September 28, 2012, John Watson, Jr. was observed shooting a handgun at a Coast Guard helicopter. The helicopter was not damaged and none of the Coast Guard employees on board was injured. Mr. Watson was indicted for attempted destruction of an aircraft (18 U.S.C. § 32(a)(1) (2009)); possession of a firearm by a felon (18 U.S.C. § 922(g)(1) (2009)); and use of a firearm during a crime of violence (18 U.S.C. § 924(c)(1)(A) (2009)). Following his arrest, Mr. Watson underwent a competency evaluation, during which he expressed the belief that he had been a covert operative for the British special forces, thereby entitling him to diplomatic immunity; that the Coast Guard and Secret Service were working to help protect him; and that his phones and computer were being tapped. Mr. Watson was deemed incompetent to stand trial and was transferred to the Federal Medical Center in Butner (FMC Butner), North Carolina, for mental health evaluation and treatment.

On April 4, 2013, the government submitted a report to the court written by an FMC Butner psychiatrist indicating that Mr. Watson had a diagnosis of delusional disorder, persecutory type, and recommending that he be forcibly medicated to restore his competency to stand trial. The government's psychiatrist made this recommendation based on his own experiences treating patients with delusional disorder and also based on “extensive support in the psychiatric literature that individuals with the diagnosis of a psychotic illness obtain substantial reduction in their psychotic symptoms when treated with antipsychotic medication” (Watson, p 421). This assertion was challenged by Mr. Watson's defense expert, who stated that there was little evidence regarding “efficacy of pharmacological treatment of persons suffering from Delusional Disorders” (Watson, p 422).

On March 7, 2014, the district court granted the government's request that Mr. Watson be forcibly medicated to restore his competency, finding that the proposed treatment was substantially likely to restore his competency as required by Sell v. United States. Under Sell, the Supreme Court ruled that involuntary administration of drugs solely for restoration of trial competence would be permitted if four prongs were met: First, a court must find that important governmental interests are at stake (Sell, p 180).Second, the court must conclude that involuntary medication will significantly further those concomitant state interests. It must find that administration of the drugs is substantially likely to render the defendant competent to stand trial.Third, the court must conclude that involuntary medication is necessary to further those interests.Fourth…,the court must conclude that administration of the drugs is medically appropriate (Sell, p 181).

The magistrate judge found that, with respect to the first Sell factor, “an important government interest is at stake in the prosecution of the defendant” and rejected Mr. Watson's argument that the government's interest was mitigated by “the possibility of an affirmative defense of not guilty by reason of insanity” (Watson, p 422). With respect to the second Sell factor, the magistrate judge found that the proposed treatment plan was substantially likely to restore Mr. Watson's competency. Mr. Watson appealed the decision, challenging the district court's findings with respect to the first and second prongs of Sell.

Ruling and Reasoning

The Fourth Circuit Court of Appeals (in a split decision) reversed the district court's decision to grant the government's request that Mr. Watson be medicated by force, stating that the district court clearly erred in finding that the government had met its burden under the second prong of Sell. In particular, the court of appeals concluded that the government had not met its burden of proof, by clear and convincing evidence, that forcible medication was substantially likely to restore Mr. Watson to competence.

The court of appeals held that the district court erred in that it did not assess the efficacy of antipsychotics as applied “with specificity to Watson's circumstances,” which is a requirement under Sell. Merely showing a proposed treatment to be “generally effective,” as the government's expert testified, was inadequate to meet the burden of proof. Rather, the legal standard would require the government to undertake “searching and individualized assessment of Mr. Watson's likely susceptibility to forcible medication” (Watson, p 428).

The court of appeals examined studies that had been cited by the government's expert and found that the available evidence for the efficacy of treatment of the persecutory type of delusional disorder with antipsychotic medication was equivocal. Although the studies could be used as evidence, the government had not applied them to Mr. Watson's specific circumstances, and thus did not provide the requisite level of clear and convincing proof that forcible injection of antipsychotic would be substantially likely to treat Mr. Watson's specific persecutory delusions. As such, the court of appeals found that the lower court had reached a conclusion against the clear weight of the record.

The appeals court held that the district court erred by relying solely on the opinion of the government's psychiatric expert, while apparently failing to consider the opinion of Mr. Watson's expert. There was no reasoning offered by the lower court for why the contrary argument was not considered. In fact, the court of appeals opined that Mr. Watson's expert had actually provided an opinion that related to Mr. Watson's situation in a more specific way than the government's expert.

The appeals court did not decide whether a possible insanity defense is a special circumstance that could mitigate the government's interest in prosecution under the first prong of Sell.

Dissent

In the dissenting opinion, Chief Judge Traxler wrote that the majority had not addressed the question actually raised by Mr. Watson in his appeal: that the district court erred by not requiring supportive therapy in addition to medication, which would have increased the likelihood that he would be restored to competency. Judge Traxler further believed the case should have been vacated and remanded for additional findings rather than simply reversing the district court's decision.

Discussion

In this case, the majority of the court of appeals ruled that, given the important liberty interests at stake, the government must be held to a high standard of proof before being granted the right to administer forced medication. In addition, the court of appeals concluded that the lower courts must conduct a searching inquiry to ensure that the government has met its burden by clear and convincing evidence. Under the second prong of Sell, simply showing that a treatment is “generally effective” is insufficient to meet this requirement.

Therefore, the government must prove that the proposed treatment will be an effective therapy for the defendant's specific disorder. To do so, the analysis of the proposed treatment requires consideration of factors, such as the defendant's age and medical condition, as well as the nature of the defendant's delusions. Such a standard is in place to prevent the government from using the same generalized evidence to prevail in all cases involving the same condition or course of treatment. Thus, forensic psychiatrists must prepare individualized treatment plans when recommending forced medications for defendants.

This case is also important, as it pertains to a condition, delusional disorder, that is difficult to treat and may have limited response to antipsychotic medications. For such disorders, psychiatric experts must be aware of the evidence for treatments of the disorder. Psychiatrists must also provide a treatment plan that is tailored to the specific situation of the defendant being evaluated. They must then be prepared to defend the proposed treatment course with available evidence and present this evidence as it pertains specifically to the individual. Furthermore, the case highlights the importance of obtaining past records, which can strengthen the argument for use of psychotropic medications if the individual has had prior response to treatment.